Abstract

Background
Exposure to childhood maltreatment (CM) increases the risk of psychiatric morbidity in youths. The new Complex Post-Traumatic Stress Disorder (CPTSD) diagnosis captures the heterogeneity and complexity of clinical outcomes observed in youths exposed to CM. This study explores CPTSD symptomatology and its association with clinical outcomes, considering the impact of CM subtypes and age of exposure.

Methods
Exposure to CM and clinical outcomes were evaluated in 187 youths aged 7–۱۷ (۱۱۶ with psychiatric disorder; 71 healthy controls) following the Tools for Assessing the Severity of Situations in which Children are Vulnerable (TASSCV) structured interview criteria. CPTSD symptomatology was explored by confirmatory factor analysis, considering four subdomains: post-traumatic stress symptoms, emotion dysregulation, negative self-concept and interpersonal problems.

Results
Youths exposed to CM (with or without psychiatric disorders) showed greater internalizing, externalizing and other symptomatology, worse premorbid adjustment and poorer overall functioning. Youth with psychiatric disorder and exposed to CM reported more CPTSD symptomatology, psychiatric comorbidity and polypharmacy and earlier onset of cannabis use. Different subtypes of CM and the developmental stage of exposure differentially impact CPTSD subdomains.

Limitations
Small percentage of resilient youths was studied. It was not possible to explore specific interactions between diagnostic categories and CM. Direct inference cannot be assumed.

Conclusions
Gathering information on type and age of exposure to CM is clinically useful to understand the complexity of psychiatric symptoms observed in youths. Inclusion of the CPTSD diagnosis should increase the implementation of early specific interventions, improving youths’ functioning and reducing the severity of clinical outcomes.

Introduction

Childhood maltreatment (CM) according to the definition of the World Health Organization (WHO) is the abuse and neglect that occurs to children under 18 years of age. Includes all types of physical and/or emotional abuse, sexual abuse, neglect and negligence, and commercial or other exploitation that results in actual or potential harm to the child’s health, survival, development, or dignity in the context of a relationship of responsibility, trust or power (WHO, 2022).

Exposure to CM might increase vulnerability to different psychiatric disorders, soon after traumatic experiences but also throughout life (Heim et al., 2010; Scott et al., 2010; Teicher and Samson, 2013). Adverse childhood experiences (ACE) occur with the exposure during childhood or adolescence to environmental circumstances that are likely to require significant psychological, social, or neurobiological adaptation by an average child with trauma being one of the possible outcomes of exposure to adversity (McLaughlin, 2016). ACEs are associated with up to 45 % of all childhood onset psychiatric disorders and with around 30 % of later-onset non-specific psychiatric disorders (McLaughlin et al., 2010). Furthermore, evidence suggests that psychological outcomes may depend upon the nature, timing, chronicity and severity of the adverse experiences (Hughes et al., 2017; Jonson-Reid et al., 2012).

Conclusions

CM is a highly complex phenomenon affecting individuals systemically and a major risk factor for dysfunctionality and a huge range of psychiatric disorders and comorbidity. The present study supports the clinical utility of gathering information on CM and adverse childhood experiences to help understand the complexity of psychiatric symptoms observed in children and adolescents exposed to complex trauma. The new diagnosis accepted by ICD-11, CPTSD, may help explain the worse clinical prognosis observed in patients exposed to CM, and may guide the development of more efficient preventive treatments and interventions focused on trauma, emotional dysregulation, negative self-concept and interpersonal problems, which are fundamental aspects during development.

Different subtypes of CM and the developmental stage of exposure differentially impact CPTSD subdomains. Specifically, emotional neglect was the most prevalent CM and contributed to all CPTSD subdomains throughout development. Although post-traumatic stress symptomatology increased with all CM subtypes, a significant effect of physical neglect only appeared after exposure during infancy (0–۵ years). Physical abuse also appears to be especially harmful when it occurs at 0–۵ years. Emotional abuse seems to be the CM subtype that best explains the variability of PTSD symptoms. PTSD can particularly result from emotional abuse suffered at age six to 12. Sexual abuse seems to be harmful and induce PTSD when occurs after age 5. Regarding DSOs subdomains, both emotional neglect and abuse, and physical abuse had a strong impact on emotional dysregulation. Negative self-concept and interpersonal problems seem to be affected by all CM subtypes. Specifically, physical neglect and abuse was of greater risk during the first 5 years of life, while emotional and sexual abuse were during primary school age (6–۱۲ years).